Stipulation With Request For Award {DWC-CA 10214(a)}



STATE OF CALIFORNIA

DIVISION OF WORKERS' COMPENSATION

WORKERS' COMPENSATION APPEALS BOARD

STIPULATIONS WITH REQUEST FOR AWARD | |

|      |Date of Injury |      |

|Case No. MM/DD/YYYY |

|      |

|SSN (Numbers Only) |

|Venue Choice is based upon: (Completion of this section is required) |

|Residence of employee (Labor Code section 5501.5(a)(1)) |

|Location where injury occurred (Labor Code section 5501.5(a)(2)) |

|Principal address of employee’s attorney (Labor Code section 5501.5(a)(3)) |

| |

|Select 3 Letter Office Code For Place/Venue of Hearing (From the Document Cover Sheet) |

|Applicant (Completion of this section is required) |

|      |  |

|First Name MI |

|      |

|Last Name |

|      |

|Address/PO Box (Please leave blank spaces between numbers, names or words) |

|      |   |      |

|City State Zip Code |

|Employer #1 Information (Completion of this section is required) |

|Insured Self-Insured Legally Uninsured Uninsured |

|      |

|Employer Name (Please leave blank spaces between numbers, names or words) |

|      |

|Employer Street Address/PO Box (Please leave blank spaces between numbers, names or words) |

|      |   |      |

|City State Zip Code |

|Insurance Carrier Information (if known and if applicable - include even if carrier is adjusted by claims administrator) |

|      |

|Insurance Carrier Name (Please leave blank spaces between numbers, names or words) |

|      |

|Insurance Carrier Street Address/PO Box (Please leave blank spaces between numbers, names or words) |

|      |   |      |

|City State Zip Code |

|Claims Administrator Information (if known and if applicable) |

|      |

|Name (Please leave blank spaces between numbers, names or words) |

|      |

|Street Address/PO Box (Please leave blank spaces between numbers, names or words) |

|      |   |      |

|City State Zip Code |

|Employer #2 Information (Completion of this section is required) |

|Insured Self-Insured Legally Uninsured Uninsured |

|      |

|Employer Name (Please leave blank spaces between numbers, names or words) |

|      |

|Employer Street Address/PO Box (Please leave blank spaces between numbers, names or words) |

|      |   |      |

|City State Zip Code |

|Insurance Carrier Information |

|(if known and if applicable - include even if carrier is adjusted by claims administrator) |

|      |

|Insurance Carrier Name (Please leave blank spaces between numbers, names or words) |

|      |

|Insurance Carrier Street Address/PO Box (Please leave blank spaces between numbers, names or words) |

|      |   |      |

|City State Zip Code |

|Claims Administrator Information (if known and if applicable) |

|      |

|Name (Please leave blank spaces between numbers, names or words) |

|      |

|Street Address/PO Box (Please leave blank spaces between numbers, names or words) |

|      |   |      |

|City State Zip Code |

|Employer #3 Information (Completion of this section is required) |

|Insured Self-Insured Legally Uninsured Uninsured |

|      |

|Employer Name (Please leave blank spaces between numbers, names or words) |

|      |

|Employer Street Address/PO Box (Please leave blank spaces between numbers, names or words) |

|      |   |      |

|City State Zip Code |

|Insurance Carrier Information |

|(if known and if applicable - include even if carrier is adjusted by claims administrator) |

|      |

|Insurance Carrier Name (Please leave blank spaces between numbers, names or words) |

|      |

|Insurance Carrier Street Address/PO Box (Please leave blank spaces between numbers, names or words) |

|      |   |      |

|City State Zip Code |

|Claims Administrator Information (if known and if applicable) |

|      |

|Name (Please leave blank spaces between numbers, names or words) |

|      |

|Street Address/PO Box (Please leave blank spaces between numbers, names or words) |

|      |   |      |

|City State Zip Code |

|Employer #4 Information (Completion of this section is required) |

|Insured Self-Insured Legally Uninsured Uninsured |

|      |

|Employer Name (Please leave blank spaces between numbers, names or words) |

|      |

|Employer Street Address/PO Box (Please leave blank spaces between numbers, names or words) |

|      |   |      |

|City State Zip Code |

|Insurance Carrier Information |

|(if known and if applicable - include even if carrier is adjusted by claims administrator) |

|      |

|Insurance Carrier Name (Please leave blank spaces between numbers, names or words) |

|      |

|Insurance Carrier Street Address/PO Box (Please leave blank spaces between numbers, names or words) |

|      |   |      |

|City State Zip Code |

|Claims Administrator Information (if known and if applicable) |

|      |

|Name (Please leave blank spaces between numbers, names or words) |

|      |

|Street Address/PO Box (Please leave blank spaces between numbers, names or words) |

|      |   |      |

|City State Zip Code |

|The parties hereto stipulate to the issuance of an Award and/or Order, based upon the following facts, and waive the requirements of Labor Code section 5313: |

|1. |      |

|Employees First Name |

|      |

|Employees Last Name |

|birth date |      |

|MM/DD/YYYY |

|while employed at |      |, |   |

|State |

|as a(n) |      |, |      |in |

|Occupation Group |

| More than 4 Companion Cases |

|Specific Injury |

|      |      |      |

|Case Number 1 Cumulative Injury |(Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) |

| |(If Specific Injury, use the start date as the specific date of injury) |

|Body Part 1: |      |Body Part 2: |      |Body Part 3: |      |

|Body Part 4: |      |Other Body Parts: |      |

| Specific Injury |

|      |      |      |

|Case Number 2 Cumulative Injury |(Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) |

| |(If Specific Injury, use the start date as the specific date of injury) |

|Body Part 1: |      |Body Part 2: |      |Body Part 3: |      |

|Body Part 4: |      |Other Body Parts: |      |

| Specific Injury |

|      |      |      |

|Case Number 3 Cumulative Injury |(Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) |

| |(If Specific Injury, use the start date as the specific date of injury) |

|Body Part 1: |      |Body Part 2: |      |Body Part 3: |      |

|Body Part 4: |      |Other Body Parts: |      |

| Specific Injury |

|      |      |      |

|Case Number 4 Cumulative Injury |(Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) |

| |(If Specific Injury, use the start date as the specific date of injury) |

|Body Part 1: |      |Body Part 2: |      |Body Part 3: |      |

|Body Part 4: |      |Other Body Parts: |      |

|by the employer(s) and their insurer(s) listed above and who sustained injury(ies) arising out of and in the course of employment to |

|      | |

|(Please list all body parts injured) | |

|2. The injury (ies) caused temporary disability for the period |      |through |

|MM/DD/YYYY |

|      |for which indemnity has been paid at $ |      |per week. |

|MM/DD/YYYY Indemnity Paid |

|2(a).The injury(ies) caused additional temporary disability for the period |      |

|MM/DD/YYYY |

|through |      |at the rate of $ |      |in the amount of $ |      |

|MM/DD/YYYY Rate Indemnity Paid |

|3. The injury(ies) caused permanent disability of |      |% for which indemnity has been paid at $ |      |

|Indemnity Paid |

|per week beginning |      |in the sum of $ |      |, less credit for such payments |

|MM/DD/YYYY |

|previously made. And a life pension of $ |      |per week thereafter. |

|Life Pension |

|Labor Code §4658(d) adjustment: |

| Increase rate to $ |      |as of |      |

|MM/DD/YYYY |

| Decrease rate to $ |      |as of |      |

|MM/DD/YYYY |

|Not Applicable |

|An informal rating has / has not (Select one) been previously issued in case no(s) |      |.|

|4.There is is Not a need for medical treatment to cure or relieve from the effects of said injury (ies). |

|5. Medical-legal expenses and/or liens are payable by defendant as follows: |

| |      | |

| | |

|6. Applicant's attorney requests a fee of $ |      |

| Fees to be commuted as follows: |

| |      |

|7. Liens Against compensation are payable as follows: |

| |      |

|8.Any accrued claims for Labor Code section 5814 penalties are included in this settlement unless expressly excluded. |

|9.Other stipulations: |

|      |

|Dated |      |      |

|MM/DD/YYYY |Applicant |

| |      |

|Applicant's Attorney or Authorized Representative: |

|Law Firm/Attorney Non Attorney Representative |

|      |

|First Name |

|      |

|Last Name |

|      |

|Firm Number |

|      |

|Law Firm name |

|      |

|Address/PO Box (Please leave blank spaces between numbers, names or words) |

|      |   |      |

|City State Zip Code |

|Dated |      |      |

|MM/DD/YYYY Applicant Attorney Signature |

|Defendant's Attorney or Authorized Representative: |

|Law Firm/Attorney Non Attorney Representative |

|      |

|First Name |

|      |

|Last Name |

|      |

|Firm Number |

|      |

|Law Firm Name |

|      |

|Address/PO Box (Please leave blank spaces between numbers, names or words) |

|      |   |      |

|City State Zip Code |

|Dated |      |      |

|MM/DD/YYYY Defense Attorney Signature |

|Defendant's Attorney or Authorized Representative: |

|Law Firm/Attorney Non Attorney Representative |

|      |

|First Name |

|      |

|Last Name |

|      |

|Firm Number |

|      |

|Law Firm Name |

|      |

|Address/PO Box (Please leave blank spaces between numbers, names or words) |

|      |   |      |

|City State Zip Code |

|Dated |      |

|MM/DD/YYYY |      |

|Defense Attorney Signature |

|      |

|Defendant's Attorney or Authorized Representative: |

|Law Firm/Attorney Non Attorney Representative |

|      |

|First Name |

|      |

|Last Name |

|      |

|Firm Number |

|      |

|Law Firm Name |

|      |

|Address/PO Box (Please leave blank spaces between numbers, names or words) |

|      |   |      |

|City State Zip Code |

|Dated |      |      |

|MM/DD/YYYY Defense Attorney Signature |

|      |

|Interpreter Licence Number: |

|      |      |

|Interpreter Name Interpreter License Number |

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